Provider Demographics
NPI:1740641406
Name:GLORY REALM HEALTHCARE CONSULTANTS LLC
Entity type:Organization
Organization Name:GLORY REALM HEALTHCARE CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:ANGELLA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:404-692-6907
Mailing Address - Street 1:2296 HENDERSON MILL RD NE STE 116
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2739
Mailing Address - Country:US
Mailing Address - Phone:404-692-6907
Mailing Address - Fax:
Practice Address - Street 1:2296 HENDERSON MILL RD NE STE 116
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2739
Practice Address - Country:US
Practice Address - Phone:404-692-6907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service